2.0 Analysis 2.1 Introduction This fire clearly illustrates the importance of having well-trained crew members who are fully familiar with their vessel so that they can properly assess the situation confronting them when something unusual happens. The training and experience of the crew and the condition of the equipment played a major role in the outcome of this fire. 2.2 Crew Training In training courses for engineers, it would perhaps be in order to stress how very important it is to follow the manufacturer's directions during maintenance operations. Considering the history of the NADINE and the RALI II, it could be expected that someone would have thought of stopping the main engine in case of an electrical power failure. After the sinking of the NADINE, the RALI II was used to conduct tests to determine the effects of loss of hydraulic pressure on the propeller pitch. Although the crew reacted well to the threat posed by the fire and each member knew exactly what his responsibilities were, the procedure for preparing to abandon ship had not been perfected as evidenced by the fact that the rafts were launched without awaiting the master's orders. 2.3 Fuel Filters The fuel filters were installed on the front of the engine, near the turbocharger and the exhaust pipe. No splashguard was fitted to prevent diesel fuel from splashing on to the engine. The cover of the filter was loosened without first emptying the filter. The drop in the pressure of the fuel supply system was not due to dirty filters but to the failed overflow valve which allowed the diesel fuel to flow back freely to the day tank. 2.4 Controllable-pitch Propeller There are alternatives that could prevent the propeller pitch from going to full astern when an electrical power failure occurs. There are pros and cons, however, to each of them, and only a thorough analysis of the possibilities can determine whether it is advantageous to implement them. 2.5 Quick-closing Valve In order to enable the remote shut-off of the fuel tanks, they are fitted with quick-closing valves activated by steel cables. It was discovered that the collar that limits the opening of the defective valve had come loose. This impaired the operation of the tripping mechanism and, as the valve did not close, the fuel supply to the main engine was not cut off. For this reason, the main engine did not stop after the remote-controlled shut-off valves were activated. 2.6 Electric/Pneumatic Controls Owing to a series of events, the propeller shaft clutch mechanism could not be disengaged and the main engine emergency stop did not work. The emergency stop system did not work because the electrical wires had been damaged by the fire. The propeller shaft clutch mechanism could not be disengaged because of the electrical power failure. These two systems had been checked during the vessel's annual inspection in the spring and had been found to be working properly at that time. 3.0 Conclusions 3.1 Findings The engine-room personnel did not follow the manufacturer's directions or sound work practices in cleaning the fuel filters. The engine-room personnel was not aware that the overflow valve of one of the fuel filters was damaged. The fire was so intense that the engine-room had to be evacuated immediately. The main engine was not stopped in the first moments of the emergency. As a result of the electrical power failure and of the loss of hydraulic pressure, the propeller pitch gradually passed to full astern. The system for disengaging the propeller shaft did not work because it operated on the 110-volt AC power source, and no attempt was made to activate it before the electrical power failure. The main engine emergency stop system operated on 24 volt DC, which was available, but the crew delayed too long in using it and, as a result, the electrical wire had already been damaged by the fire by the time attempts were made to do so. The remote-controlled shut-off valve of the day tank did not work because one of the components of the Quiclose valve had come loose, and this interfered with its operation. The liferafts were launched under unfavourable conditions and without the master's orders. The two liferafts were damaged, and their contents lost in the water, when they were dragged in the wake of the vessel as she made sternway. 3.2 Causes The fire broke out when a component of the main fuel filters of the main engine failed and the engine-room personnel undertook to clean the filters. This component failure, combined with an improper work method, caused diesel fuel to splash on to the unprotected exhaust pipes. During the fire, the main engine emergency stop remote control and that of the propeller shaft clutch mechanism failed to work. 4.0 Safety Action 4.1 Action Taken 4.1.1 Quick-closing Valves The locking collars of the fuel oil quick-closing valves were adjusted to limit the opening of the valves. The Canadian representative of the manufacturer also suggested impregnating the valve-retaining screws with a Locktite product No. 242 threadlocker. The ship's crew and shore maintenance people were made aware of the importance of this adjustment to prevent malfunction. On current and improved designs, the locking collar is no longer fitted. The TSB apprised the Canadian Coast Guard (CCG) of the circumstances surrounding the malfunctioning of these valves. Further, given the importance of fuel shut-off valves and their widespread use on vessels, including passenger vessels, the TSB indicated the need to confirm the current operational reliability of such valves. Also, the TSB highlighted the need to establish procedures for maintenance and periodic functional checks of the fuel shut-off valves. 4.1.2 Emergency Shut-down In addition to the existing main engine shut-down and electrical declutching mechanism, a direct air line with a dump valve has been installed in the wheel-house. This valve will declutch the main engine from the gear box by reducing the air pressure to the clutch to zero. This eliminates reliance on any electrical power supply to stop the vessel by de-activating the propeller shaft in an emergency situation. The manufacturer has also stressed the importance of testing the operation of the various tripping mechanisms on a regular basis. 4.1.3 Fire and Boat Drills During fire and boat drills, emergency procedures for fire in the engine-room and the relevant controls in the wheel-house are now emphasized to the officers and ship's crew. 4.1.4 Thermal Protection The shield plate protecting the main engine exhaust pipe that had been removed during previous maintenance work, has been put back in place. A steel guard plate has been fitted to provide an additional safeguard near the fuel filters which have been replaced by new parts and relocated approximately two metres away from the main engine exhaust manifold and piping. 4.2 Safety Concern 4.2.1 Fires on Fishing Vessels TSB records indicate that, between 1989 and 1993, there was, on average, 62 fires a year on board Canadian fishing vessels; over 50 per cent of these fires resulted in the loss of the vessel. During the same period, an average of 17 fires occurred in engine-rooms annually4. According to the Japanese classification society's (Nippon Kaiji Kyokai (NK)) Study Committee on the Prevention of Engine Room Fires5, the most common hazard leading to engine- room fires is fuel spray from damaged pipes. This is supported by the data from Canadian occurrences involving fishing vessels. The major causes of engine-room fires reported in Canada include fuel or hydraulic fluid from broken pipes and fittings spraying on hot engine parts; faulty electrical systems; and uninsulated exhausts in contact with flammable materials. Moreover, the 1987 CCG study into Fishing Vessel Safety6 indicated that for the period from 1982 to 1986 inclusive, the major reported causes of vessel losses were fire and explosion, which accounted for 381 occurrences. The study cited improperly installed and maintained heaters; incorrect fuse ratings for electrical circuits; improperly secured and/or fractured fuel lines; oil or gas in bilges; and improperly installed propane systems as the major reason for the fires. 4 i.e. 17 occurrences in 1989, 19 in both 1990 and 1991, 17 in 1992 and 15 in 1993. 5 Engine room fire - Guidance to fire prevention 1994, by Masaru Iwamoto et al, ClassNK. 6 A Coast Guard Study into Fishing Vessel Safety - TP 8694 Notwithstanding that the CCG has long recognized the hazards associated with fire on board fishing vessels and has issued several Ship Safety Bulletins on the subject (in 1984, 1985, and 1989), there continues to be a significant number of fires in the engine-room of fishing vessels. Given the aforementioned Canadian statistics and as a result of recent fires on large fishing vessels (such as the RALI II and the 160 gross-ton fishing vessel JUDITH SUZANNE (TSB occurrence no. M93M0005)), the Board is concerned about the extent to which engine- room fires on board vessels continue to cause significant losses in the Canadian fishing fleet. Hence, the Board will assess these types of occurrences with a view to determining the need for further safety action.